Risk Transfer Formula for Individual and Small Group Markets Under the Affordable Care Act

Pope, Gregory; Bachofer, Henry; Pearlman, Andrew; Kautter, John; Hunter, Elizabeth; Miller, Daniel; Keenan, Patricia S.

doi:10.5600/mmrr.004.03.a04

Cited by 10 publications

(2 citation statements)

References 14 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Thus, individuals who have no utilization of medical services still have an HHS-HCC risk score. Mean plan-level scores for all enrollees are used to transfer payments from low- to high-risk plans and mitigate incentives for insurers to selectively attract and enroll low-risk individuals to enhance their profitability or other enrollee selection activity by insurance companies . In the HHS-HCC model, risk scores among identical enrollees vary by metal level due to induced demand, unobserved preferences, and ability to access care.…”

Section: Methodsmentioning

confidence: 99%

Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019

et al. 2023

View full text Add to dashboard Cite

ImportanceThe Patient Protection and Affordable Care Act (ACA) individual marketplaces are a source of insurance for millions of residents in the US. However, the association between enrollee risk, health spending, and metal tier selection remains unclear.ObjectivesTo describe individual marketplace enrollees’ metal tier selections by risk score and assess enrollees’ health spending by metal tier, risk score, and spending type.Design, Setting, and ParticipantsThis retrospective, cross-sectional study analyzed claims data from the Wakely Consulting Group ACA database, a deidentified claims database built on data voluntarily submitted by insurers. Enrollees with continuous, full-year enrollment in on-exchange or off-exchange ACA-qualified health plans during the 2019 contract year were included. Data analysis was conducted from March 2021 to January 2023.Main Outcomes and MeasuresEnrollment totals, total spending, and out-of-pocket cost were calculated, stratified by metal tier and the Department of Health and Human Services (HHS) Hierarchical Condition Category (HCC) risk score for 2019.ResultsEnrollment and claims data were obtained for 1 317 707 enrollees (53.5% female; mean [SD] age, 46.35 [13.43] years) across all census areas, age groups, and sexes. Of these, 34.6% were on plans with cost-sharing reductions (CSRs), 75.5% did not have an assigned HCC, and 84.0% submitted at least 1 claim. Compared with enrollees in bronze plans (17.2%), enrollees were more likely to be classified in the top HHS-HCC risk quartile if they selected platinum (42.0%), gold (34.4%), or silver (29.7%) plans. The highest share of enrollees with $0 total spending was noted with the catastrophic (26.4%) and bronze (22.7%) plans, while gold plans had the lowest share (8.1%). Median total spending was lower among bronze plan enrollees ($593; IQR, $28-$2100) vs platinum ($4111; IQR, $992-$15 821) or gold ($2675; IQR, $728-$9070). Within the top risk score decile, CSR enrollees had less average total spending than any other metal tier by more than 10%.Conclusions and RelevanceIn this cross-sectional study of the ACA individual marketplace, enrollees who selected plans with higher actuarial value also had greater mean HHS-HCC risk scores and health spending. The findings suggest these differences may be associated with variation in benefit generosity by metal tier, enrollee’s perceptions of future health needs, or other barriers to care access.

show abstract

Section: Methodsmentioning

confidence: 99%

Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019

et al. 2023

View full text Add to dashboard Cite

show abstract

“…2014, Pope et al. 2004, 2014). This approach classifies diagnoses into 805 diagnostic groups, which are further aggregated into 189 condition categories.…”

Section: Data and Descriptive Statisticsmentioning

confidence: 99%

Continuity of Care and Risk of Readmission: An Investigation into the Healthcare Journey of Heart Failure Patients

Senot

2019

Production and Operations Management

View full text Add to dashboard Cite

We investigate the association between continuity of care mechanisms and a patient's risk of readmission in the context of one chronic condition, heart failure. We define continuity of care as the level of consistency across patient care episodes. We dynamically measure continuity of individual referring provider; continuity of physical location, which links multiple individual providers; and continuity of Accountable Care Organization, which spans a variety of individual and institutional providers. We compile a unique large‐scale dataset that includes patient‐level claims, to follow heart failure patients throughout inpatient and outpatient settings in 2014. Our final sample covers 44,129 episodes of care for 3263 patients. Using a competitive‐risks survival model, we find that all three continuity mechanisms are associated with a patient's lower risk of readmission. This exploratory study contributes to operations management literature by identifying effective integration mechanisms in the setting of healthcare delivery. In addition, by providing the first quantitative evidence for the critical role of multiple simultaneous mechanisms in ensuring continuity of care, this study offers important preliminary insights for public policy efforts.

show abstract

Improving the Performance of Risk Adjustment Systems

McGuire¹,

Zink²,

Rose³

2021

American Journal of Health Economics

View full text Add to dashboard Cite

Risk Transfer Formula for Individual and Small Group Markets Under the Affordable Care Act

Cited by 10 publications

References 14 publications

Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019

Plan Selection, Enrollee Risk, and Health Spending on the Patient Protection and Affordable Care Act Individual Marketplaces, 2019

Continuity of Care and Risk of Readmission: An Investigation into the Healthcare Journey of Heart Failure Patients

Improving the Performance of Risk Adjustment Systems

Contact Info

Product

Resources

About